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Prior Authorization

Some services require prior authorization (preauthorization) before they are performed. Obtaining a prior authorization helps us pay claims faster with no denied charges, or unexpected costs to our members. 

Urgent/emergency admissions do not require prior authorization. Once notified of admission, medical information is applied against InterQual® criteria for level of care review. 

Please follow these steps for Commercial and Medicare Advantage members.

Important to note:

  • For Part D Medicare Advantage members, the request goes directly to Express Scripts (ESI).
  • Preauthorization requirements for ASO products are contract-specific; Medicaid requirements can be found here

 

How Does it Work?

1. Find out if a code needs prior authorization.
    This works for medical drug preauthorization. Check our pharmacy page to access the formulary for details. 

    Check whether a service requires preauthorization by consulting our online Code and Comment tool. You will need to log in. 

    Using Code and Comment: 

  • Search by a procedure code or enter the procedure description.
  • You will be provided the prior authorization requirement or directed to the potential medical policy for additional clinical criteria. 

2. Submit a prior authorization
    Reviewed by BlueShield.
    Requests for the following services can be made by fax or mail. To find a prior authorization form, visit our forms page, or click on the links below:

 

Reviewed by our partners

Prior authorization requests for the following services are reviewed by our partners. This includes: 

Radiology

National Imaging Association (NIA) manages prior authorization for MRI, PET, CT scans, nuclear cardiology, and radiation oncology procedures. 

 

Submit online at National Imaging Associates or call 1-800-642-7820

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare Part D Medications

Express Scripts manages prior authorizations and Non-Formulary requests for Medicare Part D prescriptions. 

 

Submit online at Express Scripts or call 1-800-935-6103

 

View Part D prior authorization requirements.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Review your request status/decision online

    Once a request is submitted, you can visit HealtheNet to check the status of a prior authorization. For pharmacy, call customer service for pharmacy benefit drugs. Call Provider Services for medical benefit drugs (customer service     representatives can also transfer to the correct department for member-friendly experience if needed). 

 

    You and your patient will be notified once your request has been reviewed and a decision has been made. 

  • Requests reviewed by us: Decision letters are available online and can be viewed by logging in to your account. 
  • Note: This is not applicable for pharmacy. 

 

Time frames and Notifications 

 

Non-urgent care

  • (Pre-service claims) A decision is made within three business days of obtaining all necessary information. 
  • Notification for approvals and denials are made to the member or the member's designee and the member's health care provider by telephone and in writing. 

 

Urgent care

  • (Pre-service claims) A decision is made within 72 hours after receipt of the request. 
    • Urgent SUD and step are 24 hours
    • Urgent Medicare B - within 72 hours
    • Urgent Medicare D is delegated to ESI - within 24 hours
  • Notification for approvals and denials are made to the member or member's designee and the member's health care provider by telephone and in writing. 

 

Concurrent Care (not applicable for Pharmacy)

  • A decision is made within 24 hours or one business day (whichever occurs first) after the receipt of the request. 
  • Notification for approvals and denials are made to the member or the member's designee, which may be satisfied by notice to the member's health care provider by telephone and in writing. 

 

Post-Service

  • A decision is made within 30 days after receipt of the necessary information.
  • Notifications for denials are made to the member or the member's designee and the member's health care provider in writing. 

      *Please note, Medicare Part D post-service decisions will be made within 14 calendar days (delegated to ESI); Medicare Part B within 60 calendar days.